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Abstract

Background

Little is known about differences in professional care seeking based on marital status.
The few existing studies show more professional care seeking among the divorced or
separated compared to the married or cohabiting. The aim of this study is to determine
whether, in a sample of the European general population, the divorced or separated
seek more professional mental health care than the married or cohabiting, regardless
of self-reported mental health problems. Furthermore, we examine whether two country-level
features--the supply of mental health professionals and the country-level divorce
rates--contribute to marital status differences in professional care-seeking behavior.

Methods

We use data from the Eurobarometer 248 on mental well-being that was collected via
telephone interviews. The unweighted sample includes 27,146 respondents (11,728 men
and 15,418 women). Poisson hierarchical regression models were estimated to examine
whether the divorced or separated have higher professional health care use for emotional
or psychological problems, after controlling for mental and somatic health, sociodemographic
characteristics, support from family and friends, and degree of urbanization. We also
considered country-level divorce rates and indicators of the supply of mental health
professionals, and applied design and population weights.

Results

We find that professional care seeking is strongly need based. Moreover, the divorced
or separated consult health professionals for mental health problems more often than
people who are married or who cohabit do. In addition, we find that the gap between
the divorced or separated and the married or cohabiting is highest in countries with
low divorce rates.

Conclusions

The higher rates of professional care seeking for mental health problems among the
divorced or separated only partially correlates with their more severe mental health
problems. In countries where marital dissolution is more common, the marital status
gap in professional care seeking is narrower, partially because professional care
seeking is more common among the married or cohabiting.

Background

The increase in the divorce rate has received a great deal of scientific attention.
Most research has focused on the consequences of divorce or separation for ex-partners
and their children. The health consequences of divorce are also well documented, showing
the detrimental effects of divorce on both somatic [1-5] and mental health [2,6-9], with the divorced or separated experiencing higher levels of depression, stress,
and fear, as well as lower levels of self-esteem [10-20]. However, little is known about how these adverse mental health consequences translate
into the use of health care services. A few existing studies have indicated that mental
health care use and health care use in general is higher among the divorced or separated
than among the married or cohabiting, regardless of mental health status [21-24]. Compared to the married or cohabiting, the divorced or separated visit professional
health care providers like general practitioners [21], specialists [21], and psychiatrists [22] more often, and are also hospitalized more often [21,25]. Single mothers seem to suffer the most; they have more health problems and turn
to professional mental health services more frequently [26-29]. Moreover, Dutch research has indicated that the divorced or separated not only have
higher rates of mental health care use, they also have higher rates of unmet need.
This means that they are more often in a situation in which they have mental health
care needs but do not receive sufficient care [30]. On the other hand, for a subgroup of single mothers, a Canadian study found that
the higher use of professionals for mental health reasons reflected their higher rates
of psychopathology [29]. Apart from Bijl and Ravelli's study [30], the aforementioned studies were not based on a representative sample of the general
population, did not adjust for important intermediary variables or confounders like
socioeconomic status and the availability of informal support [25], or did not include data on anyone other than women [25]. Furthermore, existing studies have focused only on a single country--the United
States of America [22], the Netherlands [30], Canada [29,31], or the United Kingdom [25]. Moreover, only two studies [25,30] have focused on care seeking for mental health problems. In this study, we examine
whether there are differences between the divorced and the married in professional
care seeking due to mental health problems, using a representative sample of the population
of 29 European countries. Based on Andersen's Behavioral Model [32], we are able to identify some social structural determinants that explain these individual
differences in mental health care consumption at both the individual and the country
level. Andersen's Behavioral Model asserts that the consumption of medical care depends
on the presence of predisposing characteristics, enabling resources, and need factors.

Predisposing characteristics are those features that are present before the development of a mental health problem.
We consider household composition, education, work status, age, and gender to be relevant
predisposing features.

The predisposing characteristic that is our main interest is household composition--more
specifically, marital status. A few studies that exist show that different family
compositions are associated with different amounts of health care use [25,33] and demonstrate that there is a higher mental health care consumption among the divorced
or separated than the married or cohabiting [21-23,34]. Another relevant aspect of household composition is the presence of children. Because
divorced parents are forced to maintain contact with each other, the presence of children
in the household may have an impact on their mental health. In addition, having sole
custody of children often involves parenting strain and financial costs, making it
more difficult to find a job, make new friends, or find a new partner [35-37], all of which act as important buffers against mental health problems (e.g., [2]). On the other hand, children may add a sense of meaning to parents' lives, and older
children in particular may be an important source of practical and social support
for their parents [38,39].

Educational level also affects the amount of mental health care consumption sought.
Even after controlling for mental health status, the lower educated are less inclined
to turn to professional mental health care services [24]. Previous research has indicated that divorce is more common among the highly educated
[40], which may explain the higher mental health care use among the divorced. Recently,
however, some authors [41,42] have argued that in countries where the cost of divorce has decreased, the lower
educated are more at risk of divorce, undermining that explanation.

Work status also correlates with the use of mental health care: compared to working
people, people outside of the labor market, like the unemployed, the retired, and
housewives and househusbands, are found to be less inclined to seek professional care
because of mental health problems [24,43], even after mental health status is controlled for. Consequently, since divorced
people have an increased risk of being laid off [44,45], we could expect them to seek professional mental health care less often.

With regard to age, the risk of illness increases with age and, consequently, health
care consumption expands [43,46].

Research has also shown that women have higher health care utilization rates than
men [24,46,47]. Some research indicates that this is largely explained by the existence of gender
differences in mental health regardless of marital status [46]. Some researchers assert that being divorced or separated has a more severe impact
on the mental health of women than of men [12,48], which may explain higher mental health care consumption by divorced women. Others
explain these gender differences in service use by pointing out that women are generally
found to be more inclined to seek professional help, even after their actual need
is controlled for [49]. According to these researchers, the impact of marital status on mental health care
consumption might therefore differ by gender, with women having a higher mental health
care use rate than men.

Enabling resources are the means and knowledge needed to acquire care. To receive care, one has to possess
both financial means and the knowledge of where to go to seek help. In Europe, the
wealthy are more likely to seek out specialist care, while access to primary care
seems to be pro-poor or equal for all income groups, even after controlling for need
[50,51]. In addition, social support from relatives and friends can be considered an enabling
resource. On the one hand, social support can encourage health care use, as social
networks may help with the recognition of the development of health problems and may
stimulate a person to seek professional care [32,52-54]. On the other hand, social support may also impede health care consumption. Individuals
experiencing problems usually turn to their immediate environment for help before
contacting formal care services. However, as individuals with low levels of social
support cannot rely on the help of their acquaintances, asking for professional care
can be a way to compensate for a lack of social support [32,55]. Compared to the married and cohabiting, the divorced have smaller social networks
and less social support available to them [56]. In addition to the loss of their former partner, they also lose half of their relatives
and, often, some shared friends [38]. We therefore expect the divorced to have higher mental health care use due to less
available social support.

Need factors include health status and the perceived need for help [21,32]. On average, the divorced, compared to the married, have worse somatic [2,4,5,21] and mental health statuses. They experience higher levels of distress, depression,
and anxiety [2,6,7], and have to deal with certain somatic problems more frequently [2], often putting an extra burden on their mental health. The differences in mental
and physical health can be largely--but not completely--explained by a socioeconomic
situation that is worse and by a lack of social support [2,3,57]. Other explanations are health selection effects--healthier individuals are less
likely to divorce [2,4,58], the damaging effects of the stigmatization of divorce, and the occurrence of negative
life events as a consequence of divorce, for example, having to move [2]. Thus, the higher health care consumption of the divorced may be in large part a
consequence of worse physical and/or mental health. However, even after controlling
for these need factors, previous research indicates that the mental health care consumption
rate of the divorced seems to remain higher than that of the married [21,25]. Moreover, persons without a partner express higher unmet care needs than those living
with a partner [30].

To control for between-country differences in the distribution of our key variables--marital status and professional care consumption--we consider two country-level indicators, the country-level divorce rates and the supply of professional care.

We expect to see differences between countries in the use of mental health services
on the basis of marital status, because norms and values about family and divorce
as well as social policies about marital dissolution and sole parenthood vary between
countries [59]. At present, there is insufficient research on the link between the divorce rate
and marital status differences as they relate to mental health service use. However,
we see two possible ways in which the divorce rate might interact with the relation
between marital status and mental health services use. First, we expect to find that
higher divorce rates go hand in hand with an enhanced professional service use by
the divorced. Although more subtle forms of stigmatization are still possible [60], one can expect divorce to be less stigmatized in countries where the divorce rate
is higher [61], making it easier for the divorced to seek help [62]. Second, there are indications that the use of professional care among the divorced
could actually be lower in countries with a high divorce rate. On the basis of social
comparison theory [62] and of research on divorce and stigma [60], we can assume that people in high-divorce countries will no longer view marital
dissolution as different or problematic [7,63-65], resulting in a relative decline in professional care seeking among the divorced.
Of course, it is also possible that the divorce rate has no effect on professional
care consumption beyond the compositional effects that result from the marital status
composition of the population.

The availability of mental health services may also influence utilization [66]. We expect that the use of professional mental health care will be greater in countries
where help is available and accessible. According to Wang et al. [67], unmet need is worse in low- and middle-income countries, and the treatment gap may
therefore be attributable to the reduced amount these nations have to spend on mental
health care from health budgets that are already overburdened [66]. Consequently, we can expect cross-national variation in the availability of mental
health services to influence utilization, even among middle- and high-income European
countries. Hence, the availability of general or more specialized professionals is
a supply-side factor that should not be ignored [68] and that could be incorporated into Andersen's model as an important enabling factor
at the supra-individual level. Country-level indicators are unable to accommodate
important within-country differences in the availability of mental health services.
In order to consider these within-country differences, we also include the degree
of urbanization in the area of residence as a rough indicator of the availability
of more specialized mental health professionals [68]. Differences between rural and urban areas may also signal differences in stigma
beliefs. For instance, as Hoyt and colleagues [50] have shown, in the rural areas of the United States a reluctance to seek professional
help is closely linked to stigmatizing beliefs about mental health care.

In sum, we will first examine whether a difference exists between the married or cohabiting
and the divorced or separated in their use of professional health care for emotional
or psychological problems. Second, we will try to uncover some predisposing, enabling,
and need factors that explain this possible difference in amount of use. Finally,
we intend to examine between-country variation by introducing country characteristics--divorce
rate and the supply of services--into the analysis.

Method

Sample

We derived data from multistage national probability samples of the general population
of 29 European countries collected during the Eurobarometer 248 survey between December
2005 and January 2006. The sampling design in all participating countries was based
on a random selection of sampling areas stratified by urbanization (the distribution
of metropolitan, urban, and rural areas). A cluster of addresses were selected from
these sampled areas. In each household at a sampled address, a respondent was selected
using a random selection procedure [69]. Telephone interviews were conducted with European Union citizens residing in the
25 member countries, with the citizens of the two then-acceding countries Bulgaria
and Romania, and with the two candidate countries Croatia and Turkey including the
citizens of the Turkish Cypriot Community. In our analyses, we merged the data from
East and West Germany, from Northern Ireland and the United Kingdom, and from the
Republic of Cyprus and the Turkish Cypriot Community. For the present analysis, we
limited the sample to respondents aged 21 and older; respondents from all marital
status categories were included. We applied population weights so that each country
was represented in proportion to its population size, and we considered country-specific
design weights to correct for differences within national populations in gender, age,
region, and size of locality.

The resulting samples are representative of the population of citizens in the included
countries aged 21 and over. In total, 27,146 respondents were included (11,728 men
and 15,418 women). Table 1 presents descriptive statistics of the weighted sample.

Variables

Professional care use

The dependent variable professional care use was measured by the total number of different health professionals--general practitioner,
psychiatrist, psychologist, psychoanalyst, nurse, social worker, or psychotherapist
(not mentioned previously)--that respondents had contacted for an emotional or psychological
health problem during the last 12 months. The total number of these events followed
a Poisson distribution. Most people (85.9%) had not contacted a health professional
because of emotional or psychological problems during the past 12 months.

Health status

We included both physical and mental health status in the analysis. Physical health was measured by compiling the answers to the question "During the past 4 weeks how
much of the time have you had any of the following problems with your work or other
regular activities as a result of your physical health?" Respondents could address
the two items--"you have accomplished less than you would like" and "you have accomplished
your usual activities less carefully"--using responses ranging from all the time through never. A higher score indicates better physical health. Our physical health indicator consists
of the mean score of these two items. Scores on both items correlate very strongly
with Pearson's r = 0.85 (p < 0.001). The bivariate correlation exceeds 0.76 in all
participating countries except Denmark, where a correlation coefficient of 0.66 still
points to a strong association between both items. Mental health was based on the 36-Item Short-Form Health Survey [70], which includes both a mental health (5 items, the MHI-5) and an energy/vitality
(4 items, the EVI scale) dimension. The scale used here consists of the mean of all
nine item scores, and gives an indication of how the respondents have felt and how
things went during the last 4 weeks, with a higher score indicating a better mental
health status. A Cronbach's alpha of 0.89 demonstrates its reliability; Cronbach's
alpha exceeds 0.84 in all participating countries.

Information on physical health was lacking for 184 respondents (0.7% of the sample);
while 108 respondents (0.4% of the sample) failed to provide answers to at least six
items of the mental health dimension. Full information on these two health status
measures was available for 99.3% and 97.3%, respectively, of the sample. For both
health status indicators, the overall item mean scores replaced missing values.

Predisposing characteristics

Marital status is the main independent variable in this study. In Table 1, we compared respondents who are divorced or separated (11.8%), single (10.4%), or
widowed (12.2%), as well as a generic category of unidentified others (0.9%) to those
who are married or who cohabit (64.6%). The category of unidentified others contains
respondents who spontaneously classified themselves in this rest category. It is important
to note that we measured the current marital status: respondents who were divorced or separated but were living together
with a new partner were categorized as married or cohabiting.

The number of children (up to 15 years old), and the number of adult household members (15+) in addition to the spouse/partner were added. The reference group was a household
that had no other members besides the spouse/partner. The data did not allow us to
distinguish between children aged 16 and over and others of comparable age living
in the household.

The number of years of education the respondents had completed was subdivided into the following categories (see Table
1): 20 years or more (25.5%), 16 through 19 years (42.6%), and less than 16 years (25.4%).
Those who had studied 20 years or more were set as the reference category. Separate
categories were added for those still studying (3.2%) and those whose educational
level is unknown (3.3%).

Work status was measured on the basis of social class and employment status, using eight categories
(see Table 1): managers/professionals (10.2%), white-collar workers (10.7%), the self-employed
(7.9%), manual workers (20.8%), the unemployed (6.1%), the retired (30.0%), students
(3.2%), and housewives and househusbands (11.1%). Manual workers were set as the reference
category.

Age was measured in years and had a mean of 49.6 years with a standard deviation of 17.1
years (see Table 1).

Enabling resources

Our measure of social support was based on the question "Who would you contact for
first health support?" Multiple answers were possible. Two dichotomous indicators were constructed (see
Table 1) indicating respondents who mentioned they would seek support from their family (49.8%), and, in a separate variable, from their friends (20.1%).

The measure of the degree of urbanization of the place of residence was based on the question "Would you say you live in a rural
area or village, a small- or middle-sized town, or a large town?" People living in
a rural area or a village were set as the reference category.

Country-level characteristics

Using information provided by Eurostat [71], we determined country-level divorce rates for 2005. Like other research, the current
study used area provider density scores to measure supply-side effects [72,73].

We constructed an overall indicator of the supply of professional care by totaling
the number of general practitioners per 100,000 inhabitants, the number of psychiatrists
and psychologists per 100,000 inhabitants, and the number of psychiatric nurses or
social workers in mental health settings per 100,000 inhabitants [74].

Analysis

Hierarchical linear models were estimated using HLM version 6.0 [75]. We based our outcome variable on the number of occurrences of a relatively rare
event, namely, consulting a health professional. Therefore, due to the nature of the
dependent variable, Poisson regression analyses were appropriate [75]. We added an estimate of overdispersion, σ2, to the equations to adjust for the dependence of the variance on the mean of the
outcome indicator [76]. The intra-class correlation is 0.064 (=0.096/[0.096 + 1.41]), therefore 6.4% of
the total variance in the outcome is between-countries variance (Chi2 [df = 28] = 309.2, p < 0.001; no Table).

All variables were grand mean centered. As mentioned above, both population and design
weights were applied.

First, a baseline model was estimated, showing the results of marital status and gender
as well as the interaction effect with gender and being divorced or separated (Model
1). We added random slope estimates to account for between-country variation in the
effects of divorce on the outcome variable professional mental health care for both
women and men.

After need factors (Model 2), predisposing characteristics and enabling resources
(Model 3) were introduced. In the final model (Model 4), country characteristics and
the various cross-level interactions between divorce rate and the different marital
status categories were added. Also, all cross-level interactions between our supply
of professional care indicator and the different marital status categories were added
in addition to the random slope estimates of all marital status categories. Estimations
of this more elaborate model show significant between-country variations between all
marital status categories and professional care use, but show no significant cross-level
interaction effects with the supply of professional care. Therefore, a final, more
parsimonious, model is estimated (Model 5) after elimination of the latter cross-level
interaction effects.

The country-level descriptive statistics are shown in Table 2. Information on the supply of psychiatric nurses or social workers in mental health
settings was lacking in two countries, Belgium and Croatia. Therefore, the country-level
supply of professional care indicator for these countries was constructed after substituting
overall mean scores for missing values. We controlled for the possible effects of
this missing values substitution by adding a dichotomous indicator that identifies
both countries with partially missing information on the supply of professionals.
The results of this analysis were very close to the results reported in Tables 3 and 4: All coefficients showed similar levels of significance and the aforementioned indicator
of missing value substitution exerted no significant effect (γ = 0.054, SE = 0.263,
p = 0.838).

After including both somatic and mental health status (Table 3: Model 2), some of the aforementioned marital status and gender differences in professional
care use are found to be attenuated. Gender differences in professional care seeking
seem to be largely need based (B = 0.108, SE = 0.053, p = n.s.). The more frequent
professional care consumption of the widowed also coincides with their self-reported
health status (B = -0.093, SE = 0.065, p = n.s.). In contrast, the professional care
seeking of the divorced or separated is only partially accounted for by their somatic
and mental health status (B = 0.366, SE = 0.092, p < 0.001).

These findings remain consistent after introducing the predisposing factors (sociodemographic
controls) and enabling resources (the availability of support from friends and family)
into the model (Table 3: Model 3). Compared to the employed, both the unemployed (B = 0.165, SE = 0.093,
p < 0.05) and the retired (B = 0.246, SE = 0.082, p < 0.01) seek professional support
for mental health problems more often. Younger adults also rely on professionals more
often (B = -0.005, SE = 0.003, p < 0.01). Adding these individual-level indicators
to the baseline model does not substantially alter the strength of the random coefficients.

Finally, in Model 4 we added the two country-level indicators and the accompanying
cross-level interaction effects with divorce and the other marital status categories
(see Table 3 and 4). The country-level supply of health professionals does not exert any substantial
effect on the use of professional care. In contrast, differences in professional care
use between the divorced or separated and the married or cohabiting depend heavily
on the country-level divorce rates: In countries with high rates of marital dissolution,
the marital status differences largely disappear (Bdivorce = 0.378, SE = 0.099, p < 0.001; γdivorcerate*divorce = -0.188, SE = 0.084, p < 0.01). The estimates from the more parsimonious model (Model
5) confirm these results.

Based on Model 5, we estimated the predicted number of visits to health professionals
for the married or cohabiting and the divorced or separated at 0.11 and 0.23, respectively,
in countries with low overall divorce rates (mean minus 2 std. dev.), at 0.13 and
0.19, respectively, in countries with mean overall divorce rates, and at 0.16 and
0.16, respectively, in countries with high overall divorce rates (mean plus 2 std.
dev.). These estimated scores make it clear that in countries with a high divorce
rate the marital status gap in professional care use is smaller because of not only
lower care use among the divorced or separated, but also because of higher care use
among the currently married and cohabiting.

Discussion

Using data from the Eurobarometer 248, we estimated marital status differences in
professional care use for mental health problems in a sample of 27,146 inhabitants
of 29 European countries, 21 years and older. We found that the divorced or separated,
compared to the married or cohabiting, seek professional support more often irrespective
of mental and physical health status, and irrespective of social background (education,
work status) or of available informal support. Moreover, these marital status differences
vary from country to country. We found large differences in countries with low overall
divorce rates, irrespective of the availability of health professionals. In countries
with higher divorce rates, the marital status gap largely disappears not only because
professional care seeking among the divorced is lower, but also because the married
or cohabiting seek professional support more frequently. Before interpreting our results,
some limitations should be considered.

First, financial means are an important enabling resource in regard to professional
care [32]. Overall, low-income groups were found to use fewer mental health services, after
controlling for mental health status [19,49,59], although important differences appear when comparing general and specialized professional
support. In the present study, we were unable to consider income differences due to
the limitations of the dataset used. This meant that an important aspect of the explanation
for higher mental health care use for the divorced or separated was missing, given
that the divorced or separated--especially single parents--experience a more stringent
financial situation [60-62]. Nevertheless, the indicators of education and work status may at least partially
replace these income effects. Moreover, because we expect mental health professional
care seeking to be less among low-income groups, the inability to consider the financial
situation statistically could actually lead to an underestimation of the marital status
differences in professional care seeking.

Second, our dependent variable reflected both general and specialized professional
care use for emotional or psychological health problems. By using such a broad indicator,
we were not able to explore marital status differences in general vis-ΰ-vis specialized
professional care. The low prevalence of specialized professional care use in most
marital status categories in the present sample indicates that in future research,
larger samples are needed to differentiate between categories of professional care
and to explore their interrelatedness.

Third, we had only a very rough indicator of social support at our disposal. Respondents
were simply asked whether they could turn to friends and to family for first health
support. However, social support is important to divorced or separated people for
coping with their emotional and psychological problems, even prior to an escalation
of those problems.

Fourth, we faced some limitations concerning time. This analysis is based on cross-sectional
data, which may hinder a causal interpretation of the results. This is problematic
when considering the association between (mental) health status and professional care-seeking
behavior. Physical and mental health status was measured at the time of the interview,
while the use of mental health care in the 12 months preceding the interview was measured
retrospectively. Nevertheless, the former measurement is considered a predictor of
the latter. Longitudinal data might help circumvent this problem, but cross-national
longitudinal datasets containing information on marital status, mental health status,
and mental health professional care seeking are currently nonexistent. In addition,
we cannot rule out that possible selection effects may account for the association
between marital status and professional care seeking, as previous research has indicated
that at least a part of the relation between divorce and mental health is due to selection
effects [9,14,77,78]. However, as our results on professional care use for mental health problems are
in line with the only longitudinal study, to our knowledge, on this topic [9], we believe that a substantial part of the differences in mental health care use
is a consequence of the divorce or separation. In addition, because our study measured
professional care use during the 12 months preceding the interview, while the health
status indicators referred to only the last 4 weeks, the present results potentially
underestimate the importance of the latter. It is unlikely, however, that the lack
of comparable time frames explains the marital status differences in professional
care seeking. For instance, the present indicator of mental and somatic health status
is able to statistically explain the professional care use among the widowed; therefore
we could expect it to be a suitable need indicator for the divorced as well.

Finally, due to data limitations we could only consider current marital status. This
prevents us from distinguishing between past and current marital status. As a result,
we are unable to separate, for instance, married persons from married persons who
were previously divorced.

Despite these limitations, our results offer at least three important insights. First,
in accordance with previous research [9,10,15,21], we found that the divorced or separated, compared to the married or cohabiting,
do have a higher mental health care use, and that differences between the two groups
can be only partly explained by differences in physical and mental health. Our findings
are based on a representative sample of the population of 29 European countries. They
confirm that the more frequent professional care use among the divorced or separated
is present in most of the participating countries, albeit to varying degrees. Mental
health status has a strong impact on mental health care use and explains professional
care seeking among the widowed, and, to a substantial degree, among women. The finding
that need factors can explain health service use among the widowed but not among the
divorced corroborates previous research by Prigerson et al. [9]. These differential effects confirm that a substantial part of the mental health
care use for emotional or psychological problems among the divorced or separated relates
to factors--what Andersen calls "need factors"--other than somatic and mental health
status. However, our predisposing characteristics and enabling resources, like social
conditions related to level of education, work status, age, and the perceived availability
of support from friends and family, cannot account for this marital status effect
either. Consequently, the finding that the divorced or separated use mental health
services more often than the married or cohabiting may indicate the power of relationship
loss, bereavement, strife, or social impairment as motivators for seeking treatment
(see also [21,22]).

Additionally, we found that cross-national differences in the association between
marital dissolution and professional care use are considerable and are linked to the
average divorce rate in the participating countries. The higher the divorce rate,
the smaller the gap in professional care use between the divorced or separated and
the married or cohabiting. To the best of our knowledge, this study is the first to
document this cross-level interaction effect. Even more fascinating is the finding
that the diminished marital status gap in countries with high average divorce rates
results from both an increased professional care use for emotional or psychological
problems among married or unmarried couples and a decrease in this help-seeking behavior
among the divorced. Gelissen [63] found that the degree of tolerance towards divorce correlates with the national rate
of divorce. Therefore, the normalization of divorce [64] may account for less professional care seeking after marital dissolution in countries
with high divorce rates. In these countries, divorce is probably less stigmatizing,
or is seen as less intrinsically problematic, leading to a net decline in professional
care seeking. A post hoc interpretation of the increase in professional care seeking
among the married or cohabiting may be that in countries with high divorce rates changes
in the meaning of marriage and divorce [63,65-67] may lead both to a higher propensity among couples to proactively contact professional
care providers for marriage and relationship counseling and to less reliance on professional
support in the aftermath of a marriage breakup. In societies with high divorce rates,
a divorce culture gives way to a therapeutic culture [67] in which the married also rely on mental health professionals for counseling more
frequently. It is, in part, because of these opposing effects of the national divorce
rates on the professional care seeking of the divorced or separated versus the married
or cohabiting that we do not find overall effects of the national rates of divorce
on the mental health professional support-seeking rate. Because our analyses are based
on a comparison of current marital status categories, we cannot determine whether
this finding results from the impact of remarriage after divorce. It is still possible
that the increase of professional care seeking among the married in countries with
high divorce rates is confined to those who remarried after divorce. Analyses of cross-national
datasets containing detailed information about marital status transitions are needed
to solve this problem.

Finally, gender and work status prove to be important determinants for mental health
care use, while age and education do not seem to matter. In line with earlier studies,
we found that women use more mental health care than men do. In line with the findings
of Koopmans and Lamers [26], although contrary to other research [68], we also found that in most countries this higher mental health care use among women
can be completely attributed to self-reported poor mental and physical health. Our
hypothesis that the gap in mental health care use between the divorced and married
would be greater for women than for men could not be confirmed. Nevertheless, a significant
amount of between-country variation in the gendered effect of marital status on professional
care seeking was present, suggesting that in some countries divorce leads to increased
professional care seeking among women, while in other countries a reversed gender
difference can be observed. We did not find any effects from education, presence of
children in the household, or social support. These results contrast with what we
might expect to find [4,19,20,23,26,69]. When considering the lack of an effect for the presence of children, however, it
is possible that two opposite forces are at work: A negative "burden" effect of the
presence of children in the household [21,22] may be neutralized by a more positive effect that comes from the support children
may give to their parents [16-18]. Not having custody of one's children can be a significant stress factor as well
and thus a reason to seek professional care. This is especially relevant for divorced
fathers, who often experience significantly decreased contact with their children.
Within the divorced group, more detailed analyses are needed to refine these diverging
effects. Social support, measured as first health support, does not have a strong
influence on the consumption of different health care providers. We find a significant
but less substantial effect of the availability of friends as first health supporters,
suggesting that the availability of support from laypersons actually enhances professional
care consumption. Friends help a person gain insight into personal and emotional problems
and stimulate a person to seek professional care [30,33].

Conclusions

To the best of our knowledge, this is the first comprehensive study of a large European
sample that focuses on the differences in mental health service use between the divorced
or separated and the married or cohabiting and that considers both individual and
country characteristics. The present study has shown that the higher health care use
for emotional or psychological problems by the divorced and separated is only partly
explained by worse mental and physical health. In addition, our research clearly shows
that it is important to consider differences at the country level when studying marital
status differences in professional care use: In countries with a high national divorce
rate, the gap between the married or cohabiting and the divorced or separated regarding
use of professional mental health care diminishes dramatically. Married and unmarried
couples are more frequent user of mental health professional support, while the consumption
of professional care among the divorced or separated is lower than in countries where
divorce occurs less frequently.

In sum, we have reason to assume that in countries with high divorce rates, those
seeking professional support for mental health problems are more proactive, while
in countries where divorce is less common, the divorced seek professional support
to cope with the detrimental consequences of marital dissolution.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

PB was responsible for general coordination, participated in the statistical analysis,
supervised the drafting of the manuscript, and finalized the manuscript. EC participated
in the literature review and drafted the manuscript. SS made critical revisions to
the manuscript. LVP participated in the statistical analysis and the preparation of
the first draft of the manuscript. All authors read and approved the final manuscript.

References

Aldous J, Ganey RF: Family life and the pursuit of happiness - The influence of gender and race.